Relief Of Associated Symptoms Research Articles

Percutaneous pericardial catheter drainage for symptomatic uremic pericardial effusions with narrow safety margins.

Percutaneous pericardial catheter drainage (PCD) for pericardial effusion is generally known to be limited by the high risk associated with effusions that are less than 10 mm thick. The objective was to report cases who underwent percutaneous PCD for symptomatic uremic pericardial effusions, which were less than 10 mm thick after cardiologist declined to perform the PCDs because of the narrow safety margins. Thirteen consecutive cases (11 patients) (median age, 56 years, range, 31-83) with symptomatic uremic pericardial effusion (thickness <10 mm) affecting the pericardial space anterior to the right ventricle underwent ultrasound- and fluoroscopy-guided percutaneous PCD between September 2015 and April 2022. Information regarding the clinical criteria, echocardiographic features, PCD details, nature of effusion, and outcomes, including success and complications were retrospectively evaluated. Pigtail catheter (8.5-Fr) insertion was successful for all patients, with a median procedure time of 7 minutes (range 4~12) without procedure-related complications. The median amount of drainage on the day of PCD was 700 mL (range, 250-1100). The median duration of catheter indwelling was 5 days (range, 1~32). In one case, the catheter was removed after 1 day due to chest pain. For all patients, pericardial effusion evacuation was achieved with relief of associated symptoms, representing 100% clinical success. Percutaneous PCD may be safely performed for patients with symptomatic uremic pericardial effusions and narrow safety margins of less than 10 mm.

Gastrointestinal: Pitfalls of an abruptly elevated alpha-fetoprotein in a chronic hepatitis B carrier.

A 31-year-old male with a history of diabetes mellitus and viral hepatitis B was admitted to our hospital in March 2021 for epigastric pain, steatorrhea, and increased alpha-fetoprotein (AFP). He had a history of excessive drinking for more than a decade. Two years ago, he was admitted to another institution due to abdominal distention, and computed tomography (CT) showed enlargement of the pancreas. He then received endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) and was diagnosed with chronic pancreatitis. Since then, he lost 25 kg, despite relief of associated symptoms after medical treatment, including pancreatic enzyme preparations and prokinetics. Physical examination showed tenderness in the upper abdomen. Laboratory examination revealed the following abnormalities: white blood cell count (11.01 × 109/L), erythrocyte sedimentation rate (120 mm/h), alkaline phosphatase (163 U/L; reference range, 45–125 U/L), γ-glutamyl transpeptidase (223 U/L; reference range, 10–60 U/L), CEA (9.32 ng/mL; reference range, 0–5.00 ng/mL), AFP (3473 ng/mL; reference range, 0–20 ng/mL). Measurements of CA19–9 (21.70 U/mL; reference range, 0–34.00 U/mL) and IgG4 (0.263 g/L, reference range, 0.030–2.100 g/L) were normal. A plain/contrast CT of the abdomen revealed diffuse enlargement of the pancreas with hypodensity, focal coarse calcifications, and a capsule rim sign (Fig. 1a). Positron emission tomography demonstrated an increased uptake of 18F-FDP in the pancreatic head and uncinate process (Fig. 1b). Endoscopic ultrasound examination showed a hypoechoic mass located at the pancreatic head, and fine needle aspiration was performed (Fig. 2a–d). Based on the patient's symptoms and history (male, alcohol consumption, viral hepatitis and significantly increased AFP), the initial consultant doctor focused on screening for hepatocellular carcinoma (HCC). However, CT and positron emission tomography revealed no obvious abnormality of the liver but showed a suspicious pancreatic tumor and chronic pancreatitis (Fig. 1a,b). Though the IgG4 level was normal, considering the “sausage-like” appearance and capsule rim sign of the pancreas revealed by CT, we considered the differential diagnosis of autoimmune pancreatitis. Therefore, EUS-FNA was scheduled for further assessment. Ultrasonographic imaging showed a 4.5 × 4.2 cm hypoechoic mass in the pancreatic head, with an ill-defined border, heterogenous internal echogenicity, and diffusely scattered calcifications (Fig. 2a). Cytological examination revealed the morphology and size of the tumor cells were relatively consistent but moderately enlarged with salt-and-pepper nuclei, which are characteristics of pancreatic neuroendocrine tumors (Fig. 2b). Histopathologic findings showed a heterogenous gland pattern with irregular enlarged nuclei (Fig. 2c). The abnormal cells were found to be positive for CK7 and negative for Hep-par 1 (Fig. 2d), chromogranin A, synaptophysin, or CD56 by immunohistochemical staining (IHS). After a multidisciplinary discussion, final diagnosis was determined as pancreatic ductal adenocarcinoma (PDAC) based on histology and IHS. The patient eventually received chemotherapy consisted of gemcitabine plus capecitabine. After one cycle of treatment, the serum level of AFP rapidly decreased to 1347 ng/mL and related symptoms were relieved significantly. The patient has not returned for follow-up since then. AFP is generally used as a biomarker for HCC, yolk sac tumor, gonadal tumors, and certain types of gastric carcinomas. There are also some reports of AFP-producing pancreatic tumors, usually hepatoid carcinoma and acinar cell carcinoma. The reports of AFP-producing PDAC are rare. One possible explanation for AFP production in pancreatic cancer is the activation of the hepatic gene within the pancreas during carcinogenesis. To identify the diagnosis, histopathology and immunohistochemistry can be crucial. The level of AFP after treatment of the AFP-producing pancreatic tumor may serve as an indicator to monitor therapeutic response and recurrence.

Cefaleia pós anestesia raquidiana: uma revisão integrativa

The aim was to analyze and list the risk factors that predispose to headache after spinal anesthesia, as well as the form of prevention, through an integrative review of the literature. The study refers to an integrative review with data taken from the SciELO, Google Scholar and other databases found in the VHL (LILACS and MedLine). The 11 articles studied revealed that there are relationships between the incidence of CPR and the physiological and anatomical aspects of the patient, as well as the type of needle used in the procedure and the number of punctures. In addition, alternative therapeutic forms to the blood patch were discussed, such as the blockade of ganglia and nerves in pain control and relief of associated symptoms, which were presented in a positive way. The analysis of the different predisposing factors to headache and the treatment of this condition is essential for maximizing subarachnoid anesthesia and mitigating this adverse effect.

Sodium Valproate Versus Dopamine Antagonists for Acute Migraine in the Emergency Department: A Systematic Review.

Migraine is a common primary headache disorder diagnosed in the emergency department (ED). This systematic review sought to compare the efficacy of sodium valproate (SV) to dopamine antagonists (DA) in relieving pain due to acute migraine. Two research librarians helped create a search strategy including Embase, Ovid Medline, and the Cochrane Database of Clinical Trials from inception to June 1, 2020, updated May 19, 2021. Two investigators identified randomized control trials (RCTs) including adult patients with acute migraine presenting to the ED or acute clinical setting comparing SV to a DA with the aim of relieving pain. Primary outcome was headache relief at 1 hour from treatment. Secondary outcomes included pain relief at 24 hours, relief of associated symptoms (e.g. nausea, photo-/phonophobia, etc.), and need for rescue analgesia. Meta-analysis was performed and presented as odds ratios. Four RCTs with 470 patients were identified from an initial pool of 454 titles. Two studies compared SV to a DA alone and two compared SV to a DA plus one other agent (sumatriptan or dihydroergotamine). Three studies were included for meta-analysis. Pain relief had a pooled odds ratio of 1.14 at 1 hour and 0.42 at 24 hours. Three articles reporting the need for rescue analgesia had pooled odds ratio of 2.76. Sodium valproate is not more effective than DA at reducing migraine headache pain at 1 hour and less effective at 24 hours. Dopamine antagonists should be used over SV for the management of patients with acute migraine.

Inability to Belch and Associated Symptoms Due to Retrograde Cricopharyngeus Dysfunction: Diagnosis and Treatment.

ObjectiveTo propose and test the validity of a new syndrome called retrograde cricopharyngeus dysfunction (R-CPD) that explains inability to belch and the associated symptoms of loud gurgling noises, chest and abdominal pain/distention, and excessive flatulence, as well as to report the results of botulinum toxin (BT) injection into the cricopharyngeus muscle (CPM) for both diagnosis and treatment of R-CPD.Study DesignTo develop a case series of consecutive patients matched to the syndromic features of R-CPD, inject the CPM with BT as a concurrent diagnostic and therapeutic maneuver, and assess results.SettingBastian Voice Institute (Downers Grove, Illinois).Subjects and MethodsConsecutive (unselected) patients presenting with inability to belch and associated symptoms were matched to the proposed syndrome of R-CPD, treated with BT, and followed for effect on symptoms over time.ResultsAll 51 patients achieved ability to belch and relief of associated symptoms, and the majority seem to have “retrained” the ability to belch on a potentially “permanent” basis.ConclusionR-CPD can be diagnosed syndromically, using a symptom complex; clinical diagnosis is validated by relief of symptoms after BT injection; and BT into the CPM is an efficacious treatment, whose benefit appears to often last longer than the pharmacologic duration of action of BT.

Hyperthermic intraperitoneal perfusion chemotherapy and response evaluation in patients with gastric cancer and malignant ascites.

The present study describes the use of bidirectional chemotherapy in the treatment of patients with gastric cancer and peritoneal carcinomatosis (PC), using newly developed response criteria for the treatment of malignant ascites. In addition, the association between effusion response and survival was analyzed. Between June 2010 and May 2014, patients affected by malignant ascites secondary to unresectable PC of gastric origin were treated with a combination of systemic and loco-regional chemotherapy. Cisplatin (75 mg/m2) at an inflow temperature of 43°C was infused intraperitoneally, and docetaxel (75 mg/m2) was infused simultaneously via a peripheral vein, on day 1 every 3 weeks. The primary endpoint was overall survival rate, and the secondary endpoint was efficacy against malignant ascites using new response criteria. In total, 41 patients were enrolled, the majority of whom received 6 cycles of intraperitoneal chemotherapy in combination with hyperthermia. The majority of patients exhibited clinical regression of ascites and relief of associated symptoms. Malignant ascites disappeared [complete response (CR)] or decreased by 50% [partial response (PR)] in 73.2% of patients. No mortalities associated with the procedures occurred. The median survival time was 8.6 months, and the 1-year survival rate was 24.4%. As these new response criteria for the treatment of malignant ascites were found to be feasible, bidirectional chemotherapy may be the preferred strategy for the treatment of gastric cancer with PC. The CR, PR and non-PR groups showed significant differences in overall survival, indicating that decreased effusion was associated with improved patient survival.

Evaluating patient satisfaction with specific migraine therapy based on initial treatment expectations: the PAX study

Aims and objectives:The PAX study was a naturalistic, prospective survey evaluating treatment expectations and satisfaction in a typical French migraine population.Methods:A total of 1710 patients were recruited by 489 general practitioners across France. Despite a high drop-out rate (due to one or more deviations from protocol and/or missing data), the analysable per-protocol population (PPP) patients (n = 615) remained representative with regard to the overall migraine population. Patients ranked expectations according to four criteria at baseline, and were asked to report satisfaction for each criterion at baseline and for six consecutive attacks. The highest-ranked treatment expectation was rapid relief of headache, followed by pain-free response, relief of associated symptoms, and ability to carry on present activity, respectively.Results:At inclusion, >50% of patients were using non-specific medications (analgesics, NSAIDs), and 30% reported global satisfaction with treatment. At the end of the survey, >75% of patients were using specific medications (predominantly triptans), and global treatment satisfaction increased to 83%, independent of treatment expectation rankings at baseline.Conclusions:These survey results suggest that satisfaction with acute migraine treatment increases when specific medications are prescribed, irrespective of which treatment expectation is considered most important at baseline. This emphasizes the need for improvements in the management of migraine, to ensure that optimal treatment is being provided with regard to pharmacological intervention.

Acetaminophen, Aspirin, and Caffeine Versus Sumatriptan Succinate in the Early Treatment of Migraine: Results From the ASSET Trial—A Comment

Objective.—To address the need for a rigorous, direct comparison of prescription and over-the-counter (OTC) migraine drugs and to expand the database on early treatment of migraine. Background.—Most people who experience migraine use OTC medications to treat their symptoms, but no head-to-head clinical trials comparing these agents with prescription migraine therapies have been published. In addition, even though most migraineurs treat early in the attack, few studies have been conducted to reflect this treatment pattern. Methods.—We compared a combination of nonprescription migraine medication (acetaminophen 500 mg, aspirin 500 mg, and caffeine 130 mg) with a prescription migraine product (50 mg sumatriptan) in a randomized, controlled clinical trial in which subjects treated at the first sign of a migraine attack. Subjects who reported vomiting during more than 20% of migraine episodes or who required bedrest during more than 50% of migraine episodes were excluded from the study. Of the 188 subjects randomized, 171 took study medication and were included in the analysis. Conclusion.—The combination of acetaminophen, aspirin, and caffeine was significantly more effective (P > .05) than sumatriptan in the early treatment of migraine, as shown by superiority in summed pain intensity difference, pain relief, pain intensity difference, response, sustained response, relief of associated symptoms, use of rescue medication, disability relief, and global assessments of effectiveness. An additional, larger clinical trial is needed to confirm these results.

Acetaminophen, Aspirin, and Caffeine Versus Sumatriptan Succinate in the Early Treatment of Migraine: Results From the ASSET trial

To address the need for a rigorous, direct comparison of prescription and over-the-counter (OTC) migraine drugs and to expand the database on early treatment of migraine. Most people who experience migraine use OTC medications to treat their symptoms, but no head-to-head clinical trials comparing these agents with prescription migraine therapies have been published. In addition, even though most migraineurs treat early in the attack, few studies have been conducted to reflect this treatment pattern. We compared a combination of nonprescription migraine medication (acetaminophen 500 mg, aspirin 500 mg, and caffeine 130 mg) with a prescription migraine product (50 mg sumatriptan) in a randomized, controlled clinical trial in which subjects treated at the first sign of a migraine attack. Subjects who reported vomiting during more than 20% of migraine episodes or who required bedrest during more than 50% of migraine episodes were excluded from the study. Of the 188 subjects randomized, 171 took study medication and were included in the analysis. The combination of acetaminophen, aspirin, and caffeine was significantly more effective (P > .05) than sumatriptan in the early treatment of migraine, as shown by superiority in summed pain intensity difference, pain relief, pain intensity difference, response, sustained response, relief of associated symptoms, use of rescue medication, disability relief, and global assessments of effectiveness. An additional, larger clinical trial is needed to confirm these results.

Rofecoxib versus ibuprofen for acute treatment of migraine: a randomised placebo controlled trial

Background: Rofecoxib is a potent cyclo-oxygenase-2 inhibitor with a long duration of action. Its role in migraine has not been systematically evaluated. Aim: To study the efficacy of rofecoxib in...

Early migraine intervention with sumatriptan 100 mg in patients with a history of nonresponse to sumatriptan 50 mg: an open-label, prospective study of multiple attacks

BackgroundEarly treatment with sumatriptan tablets (50 and 100 mg) has been shown to be effective in retrospective and prospective study designs. Despite the efficacy of sumatriptan 50 mg and early intervention, however, some patients continue not to respond completely to this dose. New evidence with a scientific basis for early intervention suggests that some patients may need to treat early to prevent the establishment of central sensitization. Also, patients cite complete pain relief as the most important attribute of a migraine medication. ObjectiveThe primary objective of this study was to determine the 2-hour efficacy of sumatriptan 100 mg in achieving complete pain relief in patients with a history of nonresponse to sumatriptan 50 mg in an early-intervention treatment paradigm. Secondary end points included complete pain relief at 4 hours, consistency of complete relief in at least 2 of 3 attacks, sustained complete relief over 24 hours, satisfaction with the 100-mg dose, and relief of associated symptoms. MethodsThis open-label, prospective study was conducted at the Wesley Headache Clinic (Memphis, Tennessee). Male and female patients between the ages of 18 and 65 years who fulfilled International Headache Society classification criteria for migraine, and who had a documented history of nonresponse to sumatriptan 50 mg at 2 hours after dosing when treating in the early, mild-pain phase in at least 2 of 3 migraine attacks were eligible for the study. Patients were instructed to receive one 100-mg sumatriptan tablet at the earliest sign of pain, while still mild, in 3 subsequent migraine attacks. After each treated attack, patients were to record a detailed diary entry. ResultsTwenty patients (17 women, 3 men; mean age, 44 years) treated all 3 migraines during the early, mild-pain phase and completed the study. Of the 60 attacks treated, 48 (80%) were pain free at 2 hours, 56 (93%) were pain free at 4 hours, and 45 (75%) were pain free at 2 hours and continued to be pain free at 24 hours (sustained pain-free response). Sumatriptan 100 mg was well tolerated; none of the patients reported any adverse events. ConclusionsIn this study of migraineurs with a history of nonresponse to sumatriptan 50 mg at 2 hours after dosing in the early, mild-pain phase of migraine, increasing the dose of sumatriptan from 50 mg to 100 mg in the early-intervention paradigm, in most attacks complete pain relief was achieved for up to 24 hours. Because patients have indicated that becoming pain free was their therapeutic goal, based on the results of this study, physicians may want to consider increasing the dose of sumatriptan to 100 mg at the first sign of pain if the patient has consistently not responded to sumatriptan 50 mg in the early-intervention model.

Intranasal sumatriptan in cluster headache

Current evidence-based acute treatments of cluster headache are limited to oxygen inhalation and subcutaneous sumatriptan. Intranasal sumatriptan is a new formulation with better tolerability than the subcutaneous route. Two open-label studies suggested efficacy of intranasal sumatriptan in cluster headache. In a double-blind placebo-controlled randomized trial, patients with episodic or chronic cluster headache whose attacks lasted at least 45 minutes each treated one attack with 20 mg sumatriptan nasal spray and another one, at least 24 hours later, with matching placebo. They scored their headache on a five-point scale (very severe, severe, moderate, mild, or none) at 5, 10, 15, 20, and 30 minutes. The primary outcome measure was headache response (a decrease in pain from very severe, severe, or moderate to mild or none) at 30 minutes. Secondary outcome measures included pain-free rates, relief of associated symptoms, and rates of adverse events. Multilevel multivariate analysis was used for statistical analysis. Five study centers enrolled 118 patients in whom 154 attacks were treated: 77 with sumatriptan and 77 with placebo. The responder rates at 30 minutes were 57% for sumatriptan and 26% for placebo (p = 0.002). Pain-free rates at 30 minutes were 47% for sumatriptan and 18% for placebo (p = 0.003). Sumatriptan was also superior to placebo considering initial response, meaningful relief, and relief of associated symptoms. There were no serious adverse events. Sumatriptan nasal spray is effective and well tolerated in the acute treatment of cluster headache attacks of at least 45 minutes' duration.

A systematic review of the use of triptans in acute migraine.

A systematic review of the literature was undertaken, to consolidate evidence concerning the efficacy and safety of triptans currently available in Canada (sumatriptan, rizatriptan, naratriptan, zolmitriptan), and to provide guidelines for selection of a triptan. Data from published, randomized, placebo-controlled trials were pooled and a combined number needed to treat (NNT) and number needed to harm (NNH) was generated for each triptan. Direct comparative trials of triptans were also examined. The lowest NNT for headache response/pain-free at one/two hours is observed with subcutaneous sumatriptan. Among the oral formulations, the lowest NNT is observed with rizatriptan and the highest NNT with naratriptan. The lowest NNH is observed with subcutaneous sumatriptan. Triptans are relatively safe and effective medications for acute migraine attacks. However, differences among them are relatively small. Considerations in selecting a triptan include individual patient response/tolerance, characteristics of the attacks, relief of associated symptoms, consistency of response, headache recurrence, delivery systems and patient preference.

Evaluating the efficacy of migraine therapy.

In patient surveys and analyses of clinical trial data, patients with migraine cite rapid and complete relief of headache pain as the single most important attribute of a migraine medication. Other desirable attributes cited by patients include lack of migraine recurrence; absence of adverse effects; and relief of associated symptoms, such as nausea, vomiting, and increased sensitivity to light and noise. Data from most clinical trials of migraine drugs use standard endpoints of level of pain relief at 2 hours and percentage of patients who are pain free at 2 hours. Using these endpoints, however, a drug that relieves pain within 30 minutes after administration would be considered equivalent to a drug that does not relieve pain until 1.5 hours after administration. Because patients clearly want relief in less than 2 hours, a time to event analysis, which, in comparison trials, credits a drug for more rapid onset of effect, might be a more useful means of comparing the efficacy of 2 migraine medications. In studies using time to event analyses, the migraine medication rizatriptan has proved superior to sumatriptan in time to pain relief; time to pain-free state; and time to elimination of nausea, photophobia, and phonophobia. Based on these results, rizatriptan may better meet patients' needs than sumatriptan.

Suppression of nocturnal acid secretion with famotidine accelerates gastric ulcer healing

Although nocturnal acid secretion has been emphasized in the pathophysiology and treatment of duodenal ulcer, its importance in gastric ulcer disease has been questioned. To explore this area, this multicenter U.S. trial compared the effect of a once-daily nighttime dose of H2-receptor antagonist with placebo on the healing of gastric ulcer and relief of associated symptoms. One hundred fifty-seven patients with endoscopically verified benign gastric ulcers were randomized in a double-blind fashion to either famotidine (40 mg at bedtime) or placebo. Antacid tablets were allowed as needed. The healing rates for famotidine were 45%, 66%, and 78% at weeks 4, 6, and 8, respectively. In comparison, placebo healing rates were 39%, 44%, and 64%. These differences were statistically significant in favor of famotidine at weeks 6 (p ≤ 0.01) and 8 (p ≤ 0.05), as well as in a life-table analysis (p ≤ 0.05). Nocturnal famotidine was also significantly better than placebo with respect to time to complete relief of pain and to the percentage of patients with complete relief of pain. No concomitant factor (including ulcer size, ulcer location, smoking history, or regular alcohol use) affected healing rates in this study. Famotidine was well-tolerated and no serious clinical or laboratory adverse effects were judged to be related to this dosing regimen of famotidine. In conclusion, suppression of nocturnal acid secretion with famotidine (40 mg at bedtime) was more effective than placebo in promoting the healing of acute benign gastric ulcer and its associated symptoms. The results of this study suggest that suppression of nocturnal acid secretion alone is as effective as “around the clock” acid suppression in the healing of benign gastric ulcer.

Therapeutic Results in Patients with Vertigo due to Circulatory Insufficiency

Fifty-two patients with chronic vertigo associated with underlying circulatory insufficiency were treated with 3-6mg of Dihydroergotamine daily for about 4 weeks and followed for changes in (1) subjective vertigo, (2) vestibular function, (3) signs of disorders of the inner ear and central nervous system, (4) predisposing conditions, and (5) associated symptoms. Each sign, symptom or abnormal test result was graded as mild, moderate or severe. The therapeutic results were rated on a 5-point scale: marked, moderate, or slight improvement, no change or aggravation in comparison to the pretreatment level.(1) The improvement rate for subjective vertigo was 69%.(2) For vestibular function, the improvement rate was 25% for voluntary nystagmus, 48% for the Romberg test, 56% for the writing test, a test of deviation reaction, and 52% for the stepping test.(3) Those with disorders of the inner ear and central nervous system showed no improvement by audiometry, but in the test for nystagmus caused by labyrinthine stimulation, the improvement rate was 38%.(4) In regard to predisposing conditions, the improvement rate for OD symptoms was 73% and that for Schellong's test was 55%.(5) Relief of associated symptoms was high for nausea and vomiting (70%) and headache (50%).